The Lieutenant Governor in Council makes the Public Health Act Forms Regulation set out in the attached Appendix.

For Information only

Recommended by: Minister of Health and Wellness

Authority: Public Health Act
(section 66)

A P P E N D I X

Public Health Act

PUBLIC HEALTH ACT FORMS REGULATION

Table of Contents

Definition 1

Notice under s22 of Act 2

Notice under s23 of Act 3

Warning under s32 of Act 4

Forms 5

Repeal 6

Expiry 7

Schedule

Definition

1 In this Regulation, "Act" means the Public Health Act.

Notice under s22 of Act

2(1) A notification under section 22(1) or (2) of the Act must contain the following:

(a) the name, gender, age, date of birth, address, telephone number and personal health number of the infected person;

(b) any other demographic information relating to the infected person as specified by the medical officer of health for the regional health authority in which the infected person is located or the Chief Medical Officer of Health;

(c) the name of the disease;

(d) all clinical and epidemiologic details pertinent to diagnosis or follow-up;

(e) the name of the person reporting.

(2) A notification under section 22(3) of the Act must contain the following:

(a) the name, gender, age, date of birth, address, telephone number and personal health number of the infected person;

(b) any other demographic information relating to the infected person as specified by the medical officer of health for the regional health authority in which the infected person is located or the Chief Medical Officer of Health;

(c) the name of the disease or infecting agent;

(d) the name of the person reporting;

(e) the name of any contact identified;

(f) all clinical and epidemiologic details required for confirmation of the diagnosis or for follow-up.

Notice under s23 of Act

3 A notification under section 23 of the Act must contain the following:

(a) the name, gender, age, date of birth, address, telephone number and personal health number of the infected person;

(b) the name of the disease or infecting agent;

(c) the name of the physician who ordered the laboratory test;

(d) the name of the reporting laboratory.

Warning under s32 of Act

4(1) A warning notice under section 32(1) of the Act must contain the following:

(a) a description of the place to which the warning applies;

(b) the name of the disease involved, subject to subsection (2);

(c) any special measures or restrictions that apply in respect of the place;

(d) the name, address and telephone number of the medical officer of health who placed the warning notice or of the regional health authority that employs the medical officer of health;

(e) a statement indicating that it is an offence to remove the warning notice without the consent of a medical officer of health.

(2) Where the medical officer of health considers that it is not in the public interest to identify the disease to which a notice under subsection (1) relates, the medical officer of health may omit any reference to it by name in the notice.

Forms

5 The forms in the Schedule are the forms prescribed for the purposes of the sections of the Act indicated on them.

Repeal

6 The Forms Regulation (AR 193/85) is repealed.

Expiry

7 For the purpose of ensuring that this Regulation is reviewed for ongoing relevancy and necessity, with the option that it may be repassed in its present or an amended form following a review, this Regulation expires on April 30, 2011.

Schedule

Form 1

Public Health Act

(Section 5)

Notice of Appeal

TO: THE PUBLIC HEALTH APPEAL BOARD

(address)

AND TO: (name of regional health authority and address)

TAKE NOTICE THAT I, (name)

(address and phone number)

having been directly affected by a decision of a regional health authority and considering myself aggrieved by the decision, hereby appeal to the Public Health Appeal Board the decision of (name of regional health authority) dated , ;

AND the grounds upon which I appeal this decision are as follows:

(attach additional sheet if necessary)

SIGNATURE:

DATED at , Alberta, this day of ,

For Information Only:

1. In accordance with section 5 of the Public Health Act, an appeal to the Public Health Appeal Board may be commenced by serving a Notice of Appeal on

(a) the Public Health Appeal Board, AND

(b) the regional health authority

within 10 days of receiving notice of the decision complained of.

2. The Notice of Appeal is sufficiently served if it is left at an office of the Public Health Appeal Board or the regional health authority.

1. THAT *I have reason to believe that * (print name of person), of (address), Alberta, is infected with (print name of disease), being a prescribed disease for the purposes of section 39 of the Public Health Act, AND

2. THAT (print name of person) REFUSES or is NEGLECTING:

(strike inapplicable statement)

(a) to submit to a medical examination for the purpose of ascertaining whether or not (he/she) is infected with that disease;

(b) to submit to medical, surgical or other remedial treatment that has been prescribed by a physician and that is necessary to render the person non-infectious;

(c) to comply with any other conditions that have been prescribed by a physician as being necessary to mitigate the disease or limit its spread to others.

3. THAT the grounds upon which my (belief or knowledge) is based are as follows:

(Physician, Community Health Nurse,

Midwife or Nurse Practitioner)

DATE OF ISSUE:

TIME OF ISSUE:

DATE OF RECEIPT BY MEDICAL

OFFICER OF HEALTH:

* Strike out where the notice is based on the personal knowledge of the physician or informant.

Form 3

Public Health Act

(Section 39(2))

Certificate of a Medical Officer of Health

TO ALL OR ANY OF THE PEACE OFFICERS IN ALBERTA AND TO ALL OR ANY OF THE PHYSICIANS IN ALBERTA:

I, (print name of medical officer of health), of (address) , Alberta, Medical Officer of Health, hereby certify that (print name of person) , (date of birth) , of (address) , Alberta

1. is or may be infected with a disease which is a prescribed disease for the purposes of section 39 of the Public Health Act, AND

2. REFUSES or is NEGLECTING:

(strike inapplicable statement)

(a) to submit to a medical examination for the purpose of ascertaining whether or not (he/she) is infected with that disease;

(b) to submit to medical, surgical or other remedial treatment that has been prescribed by a physician and that is necessary to render the person non-infectious;

(c) to comply with any other conditions that have been prescribed by a physician as being necessary to mitigate the disease or limit its spread to others.

THIS CERTIFICATE IS AUTHORITY, pursuant to section 40 of the Public Health Act,

1. for any peace officer to apprehend (print name of person) and convey (him/her) to (print name of facility) within 7 days of the date of issue of this Certificate,

2. for a physician to conduct an examination of (print name of person) in the manner prescribed in the regulations under the Public Health Act AND for a physician to treat or prescribe treatment for (print name of person) in order to render (him/her) non-infectious, with or without (his/her) consent, AND for a physician to detain (him/her) at (print name of facility) in accordance with the provisions of the Public Health Act, AND

3. for a physician to prescribe any other conditions necessary to mitigate the disease or limit its spread to others.

The following precautions should be observed:

- mask or other personal protective equipment for patient and apprehending officer adequate for protection against the diseases set out in Schedule 3 to the Communicable Diseases Regulation (AR 238/85) as recommended by the Medical Officer of Health

- hand washing

(Circle appropriate precaution)

(Medical Officer of Health)

DATE OF ISSUE:

TIME OF ISSUE:

NOTE: Where this Certificate is issued pursuant to a Notice under section 39(1) of the Public Health Act, the Certificate must be issued within 72 hours of the date of service of that Notice.

Form 4

Public Health Act

(Section 43)

Order to Apprehend Recalcitrant Patient

TO ALL OR ANY OF THE PEACE OFFICERS IN ALBERTA AND TO (specify other person):

You are hereby ordered to apprehend (print name of patient), (date of birth), and to return (him/her) to (print name and address of facility) pursuant to section 43 of the Public Health Act.

The following precautions should be observed:

- mask or other personal protective equipment for patient and apprehending officer adequate for protection against the diseases set out in Schedule 3 to the Communicable Diseases Regulation (AR 238/85) as recommended by the Medical Officer of Health

1. is infected with (print name of organism) , that produces a disease that is a prescribed disease for the purpose of section 44 of the Public Health Act, AND

2. REFUSES or is NEGLECTING

(strike inapplicable statement)

(a) to submit to medical, surgical or other remedial treatment, or

(b) to comply with any other conditions

that have been prescribed by a physician as being necessary to mitigate that disease or limit its spread to others.

THEREFORE, I hereby order that (print name of person) be isolated at (name of facility) in accordance with the Public Health Act.

(Physician)

DATED at , Alberta, this day of ,

Form 6

Public Health Act

(Section 46)

Cancellation of Isolation Order

WE, (print name of 1st physician) of (address) , Alberta, Physician and, (print name of 2nd physician) of (address) , Alberta, Physician, have separately examined (print name of person) , the subject of the Isolation Order(s) issued under the Public Health Act on (date) , AND are of the opinion that (he/she)

(a) is not infectious, OR

(b) will comply with the conditions of (his/her) discharge.

THEREFORE, it is hereby ordered that the aforesaid Isolation Order(s) be cancelled.

(Physician)

(Physician)

DATED at , Alberta, this day of ,

Form 7

Public Health Act

(Section 47)

Warrant for Examination

CANADA

PROVINCE OF ALBERTA

TO ALL OR ANY OF THE PEACE OFFICERS IN ALBERTA:

WHEREAS (name of informant) has brought before me an information upon oath THAT (name of person) , (date of birth), of (address) , Alberta may be infected with a prescribed disease for the purposes of section 47 of the Public Health Act AND REFUSES or is NEGLECTING:

(a) to submit to a medical examination for the purpose of ascertaining whether or not (he/she) is infected with that disease;

(b) to submit to medical, surgical or other remedial treatment that has been prescribed by a physician and that is necessary to render the person non-infectious;

(c) to comply with any other conditions that have been prescribed by a physician as being necessary to mitigate the disease or limit its spread to others,

AND WHEREAS I am satisfied that (name of person) should be examined in the interests of his/her own health or the health of others and that the examination cannot reasonably be arranged in any other way;

THEREFORE you are hereby ordered to apprehend (name of person) and convey him/her to (name of facility) for an examination.

DATED at , Alberta, this day of ,

(Judge of the Provincial Court of Alberta)

Form 8

Public Health Act

(Sections 50 and 52)

Order to Apprehend Isolation Patient

TO ALL OR ANY OF THE PEACE OFFICERS IN ALBERTA

AND TO (specify other person)

You are hereby ordered to apprehend (print name of person) , (date of birth), and return (him/her) to (print name and address of facility) pursuant to section 50 of the Public Health Act.

The following precautions should be observed:

- mask or other personal protective equipment for patient and apprehending officer adequate for protection against the diseases set out in Schedule 3 to the Communicable Diseases Regulation (AR 238/85) as recommended by the Medical Officer of Health

- hand washing

(Circle appropriate precaution)

(Medical Director)

of (Facility)

DATED at , Alberta, this day of ,

Form 9

Public Health Act

(Section 51)

Memorandum of Transfer

(Confidential Medical Information)

TO: The Board of (name of other facility)

WHEREAS (name of person),(date of birth), is detained in (name of present facility) pursuant to:

(strike out inapplicable parts)

(a) a Certificate issued pursuant to section 39

(b) an Order issued pursuant to section 43

(c) an Isolation Order issued pursuant to section 44

(d) a Warrant for Examination issued pursuant to section 47

(e) an Order for Apprehension issued pursuant to section 50 or 52

of the Public Health Act, for examination and treatment of (name of disease) ;

AND WHEREAS for reasons of treatment or in compliance with the wishes of (name of person) it is desirable to transfer (him/her) to (name of other facility) ;

THEREFORE, I, (name of director) , Medical Director of (name of present facility) hereby authorize the transfer of (name of person) to (name of other facility) .

(Medical Director)

of (Facility)

DATED at , Alberta, this day of ,

FOR INFORMATION ONLY

The Public Health Act states:

51(1) The medical director of the facility in which a person is detained may, for reasons of treatment or in compliance with the person's wishes, transfer the person to another facility, on completing a memorandum of transfer in the prescribed form.

(2) Where a person is transferred under subsection (1), the authority to detain, control and treat the person continues in force in the facility to which the person is transferred.